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Prior Authorization Protocol
TEVETEN HCTR(eprosartan/HCTZ)

NATL
Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.
  1. FDA Approved Indications:
    • For the treatment of hypertension. It may be used alone or in combination with other antihypertensives such as calcium channel blockers.
  2. Health Net Approved Indications and Usage Guidelines:
    Hypertension:
    • Patients who have failed to achieve adequate blood pressure control
    AND
    • For non-formulary products, failure or clinically significant adverse effects to at least one of the following angiotensin II receptor blockers (ARB) or ARB combinations: Benicar (olmesartan)/Benicar HCT (olemesartan/hydrochlorothiazide), Edarbi (azilsartan)/Edarbyclor (azilsartan/chlorthalidone) or a generic ARB/ARB combination (i.e. irbesartan, losartan, candesartan, telmisartan, eprosartan, valsartan)
  3. Coverage is Not Authorized For:
    • Non-FDA approved indications, which are not listed in the Health Net Approved Indications and usage guidelines section unless there is sufficient documentation of efficacy and safety in the published literature.
  4. General Information:
    • Teveten HCT is not indicated for initial therapy.
    • Product has a boxed warning stating medication shold be discontinued as soo as pregnancy is detected. Drugs that act directly on the renin-angiotensin system can cause injury and death to the developing fetus.
    • Dual blockade of the renin-angiotensin system (RAS) with angiotensin receptor blockers, angiotensin converting enzyme (ACE) inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy.
    • Both angiotensin II receptor antagonists and ACE inhibitors have been shown to slow the rate of progression of renal disease in hypertensive patients with diabetes mellitus and albuminuria, and use of a drug from either class is recommended in such patients. Some evidence suggests that these drugs may slow the progression of nephropathy by a mechanism independent of their antihypertensive effects.
  5. Therapeutic Alternatives:
    Drug Dosing Regimen Dose Limit/ Maximum Dose
    losartan (CozaarR)

    Adult Hypertension
    25 - 100 mg PO QD
    (single or two divided doses)
    Pediatric Hypertension
    6 years: 0.7 mg/kg (up to 50 mg) - 1.4 mg/kg (up to 100 mg) PO QD
    Hypertension with LVH
    50 - 100 mg PO QD
    Nephropathy
    50 - 100 mg PO QD

    100 mg/day

    Pediatric Hypertension:
    If <50 kg, max of 50 mg/day
    If ≥50 kg, max of 100 mg/day

    losartan/HCTZ (HyzaarR)

    Hypertension + LVH
    50/12.5 - 100/25 mg PO QD
    (single or two divided doses)

    100 mg/25 mg/day

    BenicarR (olmesartan)

    Adult Hypertension
    20 - 40 mg PO QD
    Pediatric Hypertension
    20 to <35 kg: 10 - 20 mg PO QD
    35 kg: 20 - 40 mg PO QD

    40 mg/day

    Benicar HCTR (olmesartan/HCTZ)

    Hypertension
    20/12.5 - 40/25 mg PO QD

    40/25 mg/day

    valsartan (DiovanR)

    Hypertension
    80 - 320 mg PO QD
    Pediatric Hypertension
    6 to 16 years:
    1.3 mg/kg (up to 40 mg) - 2.7 mg/kg
    (up to 160 mg) PO QD

    320 mg/day

    Pediatric Hypertension:
    160 mg/day

    valsartan/HCTZ (DiovanR HCTR)

    Hypertension
    160/12.5 - 320/25 mg PO QD

    320/25 mg/day

    irbesartan (AvaproR)
    Hypertension
    150 - 300 mg PO QD
    Nephropathy
    300 mg PO QD

    300 mg/day

    irbesartan/HCTZ (AvalideR)

    Hypertension
    150/12.5 - 300/25 mg PO QD

    300/25 mg/day

    candesartan (AtacandR)

    Adult Hypertension
    8 - 32 mg PO QD
    (single or two divided doses)
    Pediatric Hypertension
    1 to <6 years: 0.05 - 0.4 mg/kg PO QD
    6 to <17 years (<50 kg): 2 - 16 mg PO QD
    6 to <17 years (>50 kg): 4 - 32 mg PO QD

    32 mg/day

    candesartan/HCTZ (AtacandR HCT)

    Hypertension
    16/12.5 - 32/25 mg PO QD
    (single or two divided doses)

    32/25 mg/day

    Edarbi (azilsartan)

    Hypertension
    80 mg PO QD;
    consider 40 mg PO QD for patients on high doses of diuretics

    80 mg/day

    Edarbyclor (azilsartan/chlorthalidone)

    Hypertension
    40/12.5 - 40/25 mg PO QD

    40/25 mg

    telmisartan (MicardisR)

    Hypertension
    20 - 80 mg PO QD
    CV Risk Reduction
    80 mg PO QD

    80 mg/day

    telmisartan/HCTZ (Micardis HCTR)

    Hypertension
    40/12.5 - 80/25 mg PO QD

    160/25 mg/day

    eprosartan (TevetenR)

    Hypertension
    400-800 mg PO QD (single or two divided doses)

    900 mg/day

    * Requires Prior Authorization
  6. Recommended Dosing Regimen and Authorization Limit:
    Drug Dosing Regimen Authorization Limit

    Teveten HCT

    Hypertension
    600/12.5 - 600/25 mg PO QD

    Length of Benefit

  7. Product Availability:
    Teveten HCT 600/12.5, 600/25 mg tablet

  8. References:
    1. Teveten HCT [Prescribing Information]. North Chicago, IL: AbVie Inc. July 2014.
    2. MicromedexR Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed: June 12, 2015.
    3. American Hospital Formulary Service Drug Information. AHFS Web site. Available at: http://www.ashp.org/ahfs/index.cfm. Accessed: June 12, 2015.
    4. Rodgers JE and Patterson JH. Angiotensin II receptor blockers: Clinical relevance and therapeutic role. Am J Health-Syst Pharm. 2001;58:671-683.
    5. 2014 Evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the eighth joint national committee (JNC8). JAMA. 2014;311(5):507-520.
    6. Clinical PharmacologyR. Tampa, FL: Elsevier/Gold Standard. Updated periodically. Accessed: June 12, 2015.
The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.